Substance Abuseand Older Adults

schonfeld@fmhi.usf.edu

Lawrence Schonfeld, PhDDepartment of Aging & Mental Health

Florida Mental Health InstituteUniversity of South Florida

Substance Use:Issues of Concern for Older Adults

Alcohol – primary focus of today’s presentation

Tobacco – a well established health risk

Prescription Medication Misuse

Over-the-Counter (OTCs) medications

Illicit Drug Use

Prevalence Rates – Ages 65+ Alcohol problems among older adults:

2%-10% of community-based 6% to 11% of hospital admissions 14% in Emergency Departments

Tobacco: About 10% are current users (similar rates for older men and older women)

Prescription Drugs 17% of hospitalizations of older adults are

related to an adverse drug reaction – a rate 6 times greater than for entire population.

OTC Products: Adults ages 65+ consume more OTC medications than any other age group.

Illicit drug use – Low rate, but increasing trend?

This 2001 report from the National Household Survey suggested that illicit drug use, binge drinking and heavy drinking among adults ages 55+ was higher than previously thought.

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Any IllicitDrug Use

Any AlcoholUse

"Binge"Alcohol use

HeavyAlcohol Use

18 to 25

26 to 34

35 to 54

55 or Older

Percentage of Adults Aged 18 or Older Reporting Past Month Use of Any Illicit Drug or Alcohol by Age Group: 2000. (source NHSDA, 2001)

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12% of 55+ age group are either binge or heavy alcohol users

What does the research tell us about older adults and substance abuse treatment?

Substance Abuse Treatment Program Admissions Age 55 or Older

by Primary Substance at Admission(DASIS Report December 2001)

Primary substances in 1999:

76.1% Alcohol

12.6% Opiates

4.5% Cocaine

1.3% Marijuana

0.7% Sedatives/Tranquilizers

0.6% Stimulants

4.1% Other

Source: 1999 Treatment Episode Data System (TEDS)

Florida’s Elder Population

Total population - about 17 million 22% are age 60 or older Among the adult population ages 18

and older, elders ages 60+ represent 28.5%

However, among adults in treatment for substance abuse problems, only 2% are age 60+

Few older adults are treated in Florida’s substance abuse treatment programs

Fiscal Year 2001-2002

Ages 18-59

98%

People age 60+ are only

2% of all adults in treatment

Source: Policy & Services Research Data Center (2003) Louis de la Parte Florida Mental Health Institute

Expert panel recommendations for screening and treating the older adult:

SAMHSA/CSAT Treatment Improvement Protocol (TIP) #26

TIP#26 Expert Panel Recommendations

1. Age-specific, group treatment that is supportive, not confrontive.

2. Attend to depression, loneliness; address losses.3. Teach skills to rebuild social support network4. Employ staff experienced in working with elders5. Link with aging, medical, institutional settings6. Content should be age-appropriate and offered at a

slower pace.7. Create a “culture of respect” for older clients8. Broad, holistic approach recognizing age-specific

psychological, social & health aspects.9. Adapt treatment as needed to address gender

issues

NIAAA (1995) recommended for individuals over the age of 65, "no more than one drink per day"

TIP#26 refinement: • Maximum of 2 drinks on any drinking occasion (New Year's Eve, weddings)

• Somewhat lower limits for women.

Treating Older Adults with Alcohol Problems

Outcomes are generally better than younger adults

Late-onset may have the best outcomes Early studies involving group treatment have

demonstrated several important points: Depression, boredom and loneliness are

frequent triggers to drinking Those entering treatment often consume

greater quantities than one might expect.

Gerontology Alcohol Project(1979-1981)

(Dupree, Broskowski & Schonfeld, 1984)

“GAP” was a day treatment program for late onset alcohol abusers ages 55+ Onset of problem after age 50 Curriculum manual provided scripted,

cognitive-behavioral and self-management skills to prevent relapse

Group treatment format Average alcohol consumption prior to

admission was 12.2 SECs on a typical drinking day (equivalent to 12 drinks/day)

Depression, loneliness reported in about 80% of cases as the antecedents to drinking.

Gerontology Alcohol Project: Alcohol consumption at admission, discharge & follow-ups for Program completers

GAP - Replications

• Substance Abuse Program for the Elderly 1986-94 (Schonfeld & Dupree, 1991, J. of Studies on Alcohol)

• Age of onset not restricted• Alcohol, medications, drugs targeted• Used the GAP approaches

• GET SMART Program at West Los Angeles VA (Schonfeld et al. 2000, J. of Geriatric Psychiatry & Neurology)

• Modified GAP to a 16 session curriculum• Use with VA outpatients

• Older Adult Services Substance Abuse Program – Tennessee – community-based project from Centerstone Mental Health Center

Characteristics of 110 GET SMART Patients(Schonfeld et al. 2000, Journal of Geriatric Psychiatry & Neurology)

• Average Age 64.71 yrs (sd=5.5) (range: 53-82)

• Diverse group:• 50.8% Caucasian, 41.7% African American• 5.8% Latino; 1.6% Asian

• Percent Homeless 34.2%• Percent living in a Domiciliary 19.8%• In Which War Served? WW II 14.4%

Korean 62.2%Vietnam 8.1%

Most recent substances used prior to admission to GET SMART program.

Alcohol Only 51.8% Street Drugs Only 9.1% Prescription Medications only 3.6% Alcohol and Street Drugs 26.4% Alcohol and Prescription Meds 5.5% Street Drugs + Prescription Meds 0.9% All three categories 1.8%

Thus, prior to admission, 38.2% were using illicit drugs, mostly in conjunction with alcohol

GET SMART - Outcomes at Six Month Follow-up

Outcome

Completed Program

(n=49 or 44.5%)

Did Not Complete

(n=61 or 55.5%)

Remained Abstinent 27 10

Abstinent at follow-up, but had had at least one slip

13 1

Returned to fulltime alcohol use at follow-up

1 19

Deceased at Follow-up 2 6

Couldn’t be located 6 11

Couldn’t follow-up for other reasons

0 14

Screening & Brief Intervention

What is the best way to identify older adults with alcohol or other substance use problems?

What are alternatives to traditional substance abuse treatment?

Focusing on primary care practice patients…

Screening Instruments that have been used with older primary care patients

S-MAST-G: Short-Michigan Alcoholism Screening Test- Geriatric Version (10 items; Yes/No format)

AUDIT (Alcohol Use Disorders Identification Test – Recommended for screening in ethnic minorities.

CAGE (4 item scale) – CAGE may lack specificity (too many false positives). Should be enhanced with questions on Quantity/Frequency of alcohol use.

Short - Michigan Alcoholism Screening Test - Geriatric Version (SMAST-G)

A 10 item screen Includes risk factors appropriate to

elders YES/NO response format Scoring: 2 or more "YES" responses

are indicative of an alcohol problem.

Source: Frederic C. Blow, Ph.D., University of Michigan Alcohol Research Center, Ann Arbor, MI

S-MAST-G 1. When talking with others, do you ever underestimate how

much you actually drink? 2. After a few drinks, have you sometimes not eaten or been

able to skip a meal because you didn't feel hungry? 3. Does having a few drinks help decrease your shakiness or

tremors? 4. Does alcohol sometimes make it hard for you to remember

parts of the day or night? 5. Do you usually take a drink to relax or calm your nerves? 6. Do you drink to take your mind off your problems? 7. Have you ever increased your drinking after experiencing a

loss in your life? 8. Has a doctor or nurse ever said they were worried or

concerned about your drinking? 9. Have you ever made rules to manage your drinking?10. When you feel lonely, does having a drink help?

CAGE

1. Have you ever felt you should Cut down on your drinking?

2. Have people Annoyed you by criticizing your drinking?

3. Have you ever felt bad or Guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover ( Eye opener)?

Scoring: Score 0 for "no" and 1 for "yes" answers. Higher scores indicate alcohol problems. A total score of 2 or greater is considered clinically significant. (Ewing, 1984).

Examples of Large Scale Screening of Older Adults Primary Care Patients:

SAMHSA funded “Primary Care Research in Substance Abuse and Mental Health Services for the Elderly” (PRISM-E)

Project GOAL Project Healthy Lifestyles

PRISM-E Screening Results(Levkoff et al. 2004)

Ages 65+; screened at 10 sites across the U.S. 34 primary care practices & 22 MH facilities Represented managed care, community health

clinics, VA facilities, & group practices Assessed at baseline, and 3 and 6 months Research assistants screened 23,828:

14% with depression and/or anxiety (more likely to be younger, female, and ethnic minorities)

6% with at-risk alcohol consumption (more likely to be younger, whites, males)

Patients with MH/SA problems randomly assigned: Integrated model = MH & SA brief intervention

co-located with PCP Enhanced referral model (MH & SA provider is

separate) models of MH/SA care Results still being analyzed and in-press.

Project GOAL: Guiding Older Adult Lifestyles Screening (Fleming, Manwell, Barry, Adams, & Stauffacher 1999)

At-risk drinkers age 65+ in primary care practice settings involving 43 family physicians in 24 sites in 10 Wisconsin counties

Men and women ages 65-85 seeking routine care in community primary care clinics

11% of 6,000 screened positive. Inclusion criteria: Males had to consume 11 or more drinks/week or 2 or more positive responses on the CAGE

or be a binge drinker Females: 8 drinks or more per week, etc.

Eligible patients agreeing to participate were randomly assigned to brief intervention (n= 87) or usual care (n= 71)

Project GOAL: Brief Advice - Method (Fleming et al. 1999)

In Brief Intervention, the physician: States his/her concern Provides specific feedback to patients on how

their drinking is affecting them (e.g., elevated blood pressure, liver function problems, family problems).

Gives a clear recommendation about changing their alcohol use.

Negotiates a drinking contract. Provides a self-help (Health Promotion) booklet Establishes follow-up procedures.

Brief Intervention = 2 physician-delivered 15-min face-to-face visits (one month apart)

Follow-up: by a nurse via telephone at 2 weeks, 3, 6, and 12 months.

Project GOAL: Results (Fleming et al. 1999)

Results: 34% reduction in seven-day alcohol

use. 74% reduction in mean number of binge

drinking episodes. 62% reduction in percentage of older

adults who had consumed more than 20 drinks per week at the beginning.

Further research extended follow-up to two years, also with positive outcomes.

Extending Brief Interventions Beyond the

Physician’s Office

Health Profiles Project (Michigan)

• Largest randomized trial of brief alcohol advice to at-risk drinkers 60+ in primary care settings.

• 14,060 patients screened• 454 entered randomized trial• Outcome: (preliminary results)

• Over 12 months: 30% decrease in experimental group and 20% decrease in control group alcohol consumption

In-Home Brief Intervention for older primary care patients with alcohol problems

Staying Healthy Project (Cullinane, Blow, Barry, et al. – in progress)- Screened 4,300+ older adults in

California- 166 people entered randomized trials - 39% decrease in Experimental- 28% decrease in Control

• Decline in drinking in both groups suggests that bringing attention to drinking may result in decrease.

The Florida BRITE Projectfunded by the Florida Dept. of Children and Families

BRief Intervention and Treatment for Elders

Broward County Elderly & Veterans Services

Gulf Coast Community

Care

Coastal Behavioral HealthCare

The Florida BRITE ProjectBRief Intervention & Treatment for Elders

Center for Drug Free

Living – added in 2005

Orlando

The Florida BRITE Project BRITE identifies older adults who misuse or are at

risk for misusing: Alcohol Prescription medications Over-the-counter (OTC) medications Illicit drugs

Depression and suicide risk are also being screened by BRITE providers since: Depression is the most frequent antecedent to

substance abuse in elders Few older adults participate in behavioral health

services Older adults have the highest rate of suicides

among all age-groups.

No

Yes

Pre-Screening by Nontraditional and other referral sources

Screening by BRITE Pilot Program

Client screens positive and agrees to be served.

End ScreeningRe-contact at

later date

Admit person for services appropriate to service plan

BriefIntervention

BriefTreatment

Refer to external services as

indicated in plan

Re-screen client prior to discharge

Completion of every six B.T. sessions,

discharge, 30 & 90 days

Re-Assess at Discharge, 30 and 90 days

post discharge

Enter Data & upload to KIT

Enter ScreeningData on Tablet PC &

upload to KIT Solutions

Enter data into ETIPS & upload

The Florida BRITE Project - Goals

Implement evidence-based/best practice approach based on CSAT’s Treatment Improvement Protocols (TIP) Substance Abuse & Older Adults TIP #26 Brief Intervention & Brief Therapies TIP #34

Develop referral networks, screening and services appropriate for older adults in order to reach greater numbers of elders.

Follow SAMHSA’s model of Screening, Brief Intervention, Referral and Treatment (SBIRT)

The Florida BRITE Project’s Criteria:

• Focus is on helping underserved elders: • Minorities• Low Income• Isolated, withdrawn individuals

• “Non-traditional” substance abuse referral sources to identify hidden abusers

• Screen where elders are more likely to be found or interviewed:• In their own homes• Elder-specific living, centers

• Brief Interventions in home or on-site• Brief Treatment if needed (CBT/Self-Mgt.)

Pre-Screening for BRITE

• Prescreening through “traditional” referral sources for substance abuse services may not be appropriate for elders.

• Link with agencies that more likely to serve older adults with problems:

• Aging Services (AAA, County Aging)• Protective services• Visiting Nurses• Geriatric physicians• Assisted living facilities• Mental health centers• Health clinics

BRITE Screening Tool

All screens in the public domain (no copyright infringement, free to use)

Easy to administer by staff member regardless

Easy for older adults to comprehend

Translated into Spanish for BRITE Project

Includes both client self-report and the interviewer’s impressions

Includes questions on substance use history and treatment

Alcohol Screening

Ever consumed alcohol? Recent use of alcohol Quantity consumed on typical day 10 item screen S-MAST-G

administered only if the individual indicates recent use of alcohol.

Interviewer's impressions of the personafter completing the "Brown Bag Review" ofprescriptions:

1. Does not correctly recall the purpose of one or more medications

2. Reports the wrong dose/amount of one or more medications

3. Takes one or more medications for the wrong reasons or symptoms

4. Needs education and/or assistance on proper medication use

Medication Misuse – “Brown Bag” Review

Medication Use: Client Interview Items

• Takes more than one type of prescribed medication• Difficulty remembering how many meds to take• Prescriptions from two or more doctors• Felt worse soon after taking meds• Taking meds to help sleep• Uses up meds too fast• Takes meds for nervousness or anxiety• Doctor/nurse expressed concern about use of meds• Take pain relieving meds• Take pills to deal with loneliness, sadness• Saving old medications for future use• Chooses between cost of meds and other necessities• A family member reminds them to take pills• Uses dispenser or other method to help remind• Fails to take meds supposed to• Borrow someone else's meds• Feel groggy after taking certain medications

OTC Medication Use – Client Interview Items

1. Do you frequently take aspirin, Tylenol, Advil, or other non-prescription pills for pain?

2. Do you ever tell your physician about the type of non-prescription pills you buy?

3. Do you use herbal pills such as Ginkgo, Saw Palmetto, St. John's Wort?

4. Do you take non-prescription pills or remedies for improving your memory?

5. Have you ever felt worse soon after taking over-the counter remedies?

6. Are you taking medications to help you sleep?

7. Do any of the non-prescription pills you take make you feel groggy?

8. Do you use plants or herbs to make your own remedies such as garlic, or aloe?

The need to screen for

illicit drug use.

An increasing trend among older adults?

Drug Use

Use of any of the following in past year:

1. Marijuana?

2. Cocaine?

3. Crack?

4. Heroin?

5. Hallucinogens (such as LSD, PCP)?

6. Substances - sniffed or inhaled?

Recorded by interviewer - YES/NO format. Any YES responses results in a Flag for further assessment.

Short - Geriatric Depression Scale

1. Are you basically satisfied with your life? 2. Have you dropped many of your activities

and interests? 3. Do you feel that your life is empty? 4. Do you often get bored? 5. Are you in good spirits most of the time? 6. Are you afraid that something bad is going to happen to you? 7. Do you feel happy most of the time? 8. Do you often feel helpless? 9. Do you prefer to stay at home, rather than going out and doing new things?10. Do you feel you have more problems with memory than most?11. Do you think it is wonderful to be alive now?12. Do you feel pretty worthless the way you are now?13. Do you feel full of energy?14. Do you feel that your situation is hopeless?15. Do you think that most people are better off than you are?

Scoring:

5-9 = mild to moderate depression

10+ = serious levels of depression

Suicide Risk Items *

1. Has anyone in your family ever committed suicide?

2. If yes, who in your family committed suicide?

3. Have you ever thought about taking your life?

4. How recently have you thought about killing yourself?

5. Do you have a plan for doing this? (response selected from list of plans provided)

6. Have you ever been in the care of psychiatrist, psychologist, or other professional because of severe depression or mental problems?

7. Do you keep firearms in the house?

8. If yes, ask how many guns are in the house?* Adapted from Brown & Bongar (2004) Assessing risk for completed suicide in

elderly patients: Psychologists' views of critical risk factors. Professional Psychology: Research and Practice.

Florida BRITE Project:

Brief Intervention

Resource for Pilot Program

Participants:

Health Promotion Workbook

Barry, Oslin, & Blow (1999)

(modified to include drugs, medications, OTCs, depression and suicide risk)

Resource for Pilot Program

Participants:

Health Promotion Workbook

Workbook Topics: Identify future goals for physical

and emotional health, activities, finances.

Summarize health habits: Exercise, tobacco, alcohol,

nutrition Alcohol use

What is a standard drink Types of older drinkers Consequences of drinking Reasons to quit or cut down Drinking agreement Drinking diary card Handling risky situations Visit summary

Resource for Pilot Program

Participants:

Health Promotion Workbook

Workbook Topics (continued): Medication misuse

Reasons for taking wrong dose

Things to tell your doctor Do’s and Don’ts for taking

medications Potential problems with OTC

Medications

Visit summary

Brief Interventions can be delivered where older adults can be found

In the elder’s home Senior center, congregate meal sites Home Health Care Physician’s office ER’s or Hospital rooms Workplace Even within the Substance Abuse

Treatment Program!

Brief Treatment

A 16-session curriculum manual for conducting brief

treatmentDupree & Schonfeld

(CSAT, 2005)

A Three Stage CBT/Self-Management Treatment Approach

(Dupree & Schonfeld, CSAT 2005)

1. For each person in treatment, begin by conducting an analysis of the antecedents and consequences for substance use to create an individualized “substance use behavior chain” - Substance Abuse Profile for the Elderly

2. Teach the person how to identify the components of that chain so that he or she can understand the high risk situations for alcohol or drug use.

3. Teach specific skills to address these high risk situations to prevent relapse.

* Manual designed for group treatment. Includes complete word-for-word curriculum, exercises, assessments, homework assignments, and more.

Self-Management Skills for Older Alcohol Abusers

High Risk Situation Skills Taught

Social Pressure Drink Refusal

Loneliness Rebuild Social Network

Depression Cognitive Restructuring

Thought-stopping

Anxiety Relaxation, Problem solving

Thought-stopping

Anger/Frustration Assertiveness Training

Cues How to dispose, avoid, rearrange

Urges Thought-stopping, Learn to Delay

Slips Relapse Training

BRITE – Screenings fromMarch 2004 through Jan. 2006

• 1,990 screened by 4 agencies:• Broward Co. Elderly & Veterans Serv = 1,411• Gulfcoast Community Care (Pinellas) = 365• Coastal Behav. Health Care (Sarasota) = 186• Ctr. for Drug Free living (Orange)* =

28* began in August 2005

• Most (67%) are identified through BRITE outreach, presentations to the public, visits to senior centers, etc.

Demographics

Living arrangements: 56% alone 22% with spouse 8% in group setting (e.g., ALF)

69% were women Median age = 76 Race

76% Caucasian 17% African Amer. 6.7% multiracial

Hispanic 14%

Florida BRITE Project Screening:Alcohol Problems

8.5% of those referred to BRITE were for potential alcohol problems

39% of all 1,990 screened were drinkers 16% of drinkers consumed 3 or more

drinks on a drinking day 68% of referrals for alcohol problems and

5% of those referred for other reasons scored 2 or more on the S-MAST-G.

292 clients provided services – mostly brief intervention. Many of these showed other symptoms.

Florida BRITE Project Screening:Prescription Medications

18% were referred for prescription misuse 16% reported wrong amount for one or more

medication 11% could not recall purpose of one or more

medications 17% need education and/or assistance on

proper medication use 4% took prescription medications for wrong

reasons or symptoms

Florida BRITE Project Screening:

Over-the-Counter Medications

• 2.4% referred for potential OTC misuse

Illicit Drug Use

< 1% referred to BRITE for illicit drug use

Florida BRITE Project Screening: Depression

71% of all 1,990 were referred for depression

Screening these with the Short-GDS: 20% of those referred had moderate

depression Another 7% with serious depression Similar proportions for those not referred

specifically for depression

Florida BRITE Project Screening:Suicide Risk

Only 0.6% referred for suicide risk Yet, 14% of all referrals indicated that

they contemplated suicide at some time 49% of these within the past year

Services Provided based on the limited data entered:

Preliminary Outcomes: Significant improvement in Geriatric

Depression Scores (S-GDS) for 156 of the 161 people screened (p<.001)

Significant improvement in S-MAST-G (alcohol screening) at discharge for 69 people receiving re-screening (p<.001)

Conclusions

Screening older adults for substance misuse should focus on “at-risk” behaviors as well as more serious problems (involving dependence and tolerance)

Screening should be addressed in: Primary care Aging services, senior centers, etc. Health clinics

Likely to see signs of depression associated with substance misuse

Difficult to identify medication misuse, since it is a nebulous construct and requires review of patient characteristics and prescribing practices.

Beware… The Baby Boomers are getting older!